In Case You Missed It, The Problem with IMR is UR

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In case you missed it:

The Problem with IMR is UR
by Adam Dombchik and Tom Martin
Published: November 13, 2013


FOR IMMEDIATE RELEASE: Wednesday, November 14, 2013
Contact: Steve Hopcraft 916/; Twitter: @shopcraft
We read David DePaolos timely column, "IMR The New Game in Town" (Sept. 24) with great
interest, and we wish to suggest a completely different explanation for the current independent
medical-review crisis: out-of-control utilization-review (UR). We have witnessed utilization-review
denial after denial for many years.

As advocates for injured workers, we spend every day of every week trying to obtain appropriate
medical care to assist our clients in returning to work. In our experience, UR is most often used
to deny legitimate medical care, which generates disputes and frictional costs.

The underlying fact about the IMR requests is the enormous number of utilization-review denials
issued in August of 2013 alone. There were 15,731 reported utilization-review denials, resulting
in 15,731 independent medical reviews. The IMR appeals occur because the pre-programmed
UR denial machinery is running at full steam, and without reference to the actual merits or costs
associated with the treatment request. For example, the cost of UR and IMR for an X- ray is
much more costly than the X-ray itself. Anyone outside of our system would be calling for an

The preponderance of UR denials overrules insurers own doctors, 80% of them are employer
vetted and selected. So, of the 15,000 IMR applications in August, 12,000 of them are treatment
requests by the employer’s own physicians. It is reasonable for injured workers to seek IMR
vindication of the employers treating doctor’s recommendation, particularly when the treatment
is lost for a year if no application is filed. IMR is doomed to fail if invalid, unjust, unethical, and
inefficient utilization review continues to run rampant.

We are very concerned that independent medical-review requests in California workers
compensation are 30 times higher than group health. The estimated fees collected by Maximus in
August alone were $9 million dollars, a projected annual cost of $100 million. We have been
alarmed at how many treatment requests by treating physicians do not comply with the rules,
resulting in unnecessary delays. We are disappointed at how little education has been offered to
treating physicians to get it right.

Under Senate Bill 863, the language of the statute boxes the worker in with only one, limited
method of redress: file an IMR application. There are harsh consequences to an injured worker
who does not exert their right to file an IMR application. They lose the right to re-request the
same medical treatment for 12 months. There are no other appeals processes afforded in the new
law for the injured worker if a utilization-review denial is invalid.

The stability of the workers compensation system in part depends on efficient and reasonable
treatment cost containment. Workers should have access to quality and effective medical
treatment to assure rapid and optimal recovery. When necessary treatment is delayed, both the
financial and physical outcome is worse for the employee (i.e., prolonged temporary total
disability, higher permanent disability, greater financial loss, greater risk that public benefits will
be necessary). And the delay in getting back to work results in a costly, adverse affect on the
employer as well.

Consider this: Every single IMR application reflects a rejection of the treating physicians
requests for care that he or she believed would help restore the injured worker to health and

UR companies exist to control medical costs. But the more reviews a UR company does, the
more money it makes. The discretionary function of insurance adjusters to perform their role i.e.,
adjust benefits including authorization of reasonable medical treatment has been hijacked by the
UR industry. In many cases, the adjuster has no discretion, or even involvement, on the review of
medical-treatment requests. The ultimate measure of a UR companys "success" is not whether
the requested medical treatment was reasonable, but rather how much of the medical treatment
was avoided/denied.

We call for an investigation of the UR process to protect the integrity of the dispute-resolution
process and assure that it is not abused by carriers at the expense of workers health and costs,
which are then passed on to employers in the form of premiums. The current penalty scheme is
not sufficient, and the people who are penalized are the injured worker and the employer.

Investigators should examine:

How many cases cost more for UR/IMR than the cost of the recommended medical

How many UR cases denied multiple treatment requests while the employer was still
paying temporary disability compensation and the injured worker remained restricted
from returning to work?

How many utilization-review denials failed to follow the protocol that is required of an
independent medical reviewer?

Until the UR process is strictly regulated and policed, it will continue to threaten the integrity of
the IMR process.

Adam Dombchik and Tom Martin are board of director members for the California Applicants
Attorneys Association (CAAA).

Redistributed with the permission of workcompcentral.
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